General Information

• It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.
• The guideline criteria in the following sections were developed utilizing evidence-based and peer-reviewed resources from medical publications and societal organization guidelines as well as from widely accepted standard of care, best practice recommendations.

Scope
Spinal surgeries should be performed only by those with extensive and specialized surgical training (neurosurgery, orthopedic surgery). Choice of surgical approach is based on anatomy, pathology, and the surgeon's experience and preference.

Instrumentation, bone formation or grafting materials, including biologics, should be used at the surgeon’s discretion; however, use should be limited to FDA approved indications regarding the specific devices or biologics.

Special Note
In order for surgeries to be considered medically necessary there must be clear medical records that demonstrate a clear surgical plan that matches the request for surgery.

Policy
INDICATIONS
Fusion Surgery (Any Region) for the Treatment of Spinal Neoplasm, Lesion, or Infection
One of the following criteria must be met for urgent intervention:

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with worsening spinal cord compression due to tumor or infection — immediate surgical evaluation is indicated. Signs or symptoms may include any of the following ^(1,2):
  • Upper extremity weakness
  • Unsteady gait related to myelopathy/balance or generalized
  • Lower extremity weakness
  • Disturbance with coordination
  • Hyperreflexia
  • Hoffmann sign
  • Positive Babinski sign
  • Clonus
• Progressive neurological deficit (motor deficit, bowel or bladder dysfunction) with evidence of spinal cord or nerve root compression due to tumor or infection on magnetic resonance imaging (MRI) or computed tomography (CT) imaging—immediate surgical evaluation is indicated
• When ALL of the following criteria are met:
  • Evidence of gross biomechanical instability resulting in acute neurological risk requiring surgical reconstruction/fusion
  • Imaging studies demonstrate evidence of infection or neoplasm of the spine. Findings must align with corresponding clinical findings. Imaging studies may include:
    • Magnetic resonance imaging (MRI); preferred study for assessing spine soft tissue (including the spinal cord and roots)
    • Computed tomography (CT) - with or without myelography - indicated in individuals who have a contraindication to MRI; preferred for examining the spine’s bony structures

Decompression Surgery (Any Region) for the Treatment of Spinal Neoplasm, Lesion, or Infection ^(3-5)
One of the following criteria must be met:

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with worsening spinal cord compression due to tumor or infection— immediate surgical evaluation is indicated. Signs or symptoms may include any of the following:
  • Upper extremity weakness
  • Unsteady gait related to myelopathy/balance or generalized lower extremity weakness
  • Lower extremity weakness
  • Disturbance with coordination
  • Hyperreflexia
  • Hoffmann sign
  • Positive Babinski sign
  • Clonus
• Progressive neurological deficit (motor deficit, bowel or bladder dysfunction) with evidence of spinal cord or nerve root compression due to tumor or infection on MRI or CT imaging—immediate surgical evaluation is indicated
• When ALL of the following criteria are met:
  • Clinical exam findings confirm significant radiculopathy or severe axial pain
  • Imaging studies demonstrate evidence of infection or neoplasm of the spine that align with corresponding clinical findings. Imaging studies may include:
    • Magnetic resonance imaging (MRI); preferred study for assessing spine soft tissue (including cord and roots)
    • Computed tomography (CT) - with or without myelography - indicated in individuals who have a contraindication to MRI; preferred for examining the spine’s bony structures

Rationale
SUMMARY OF EVIDENCE
An Overview of Decision Making in the Management of Metastatic Spinal Tumors⁽⁵⁾

• Study Design: This is a narrative review that provides an overview of decision-making and current treatment options for metastatic spinal tumors. The review is based on a MEDLINE literature search for studies in English reporting on human subjects.
• Target Population: Patients with metastatic spinal tumors.
• Key Factors: The review discusses the multidisciplinary management of metastatic spinal tumors, emphasizing the importance of effective pain management, achieving local tumor control, adequate neurological decompression, and surgical stabilization. It highlights the evolution of treatment strategies, including limited decompression followed by postoperative stereotactic body radiotherapy (SBRT) as the current standard of care.

Systemic considerations for the surgical treatment of spinal metastatic disease: a scoping literature review⁽²⁾

• Study Design: This is a scoping literature review conducted by the AO Spine Knowledge Forum Tumor group. The review follows a framework derived from Arksey and O’Malley and adheres to the PRISMA-ScR checklist.
• Target Population: Adult patients (≥18 years) surgically treated for spinal metastatic disease.
• Key Factors: The review aims to summarize emerging evidence relating systemic considerations to clinical outcomes following surgery for spinal metastatic disease. It identifies preoperative systemic variables negatively associated with postoperative outcomes, including demographics, medical comorbidities, biochemical abnormalities, low muscle mass, generalized motor weakness, poor ambulation, reduced performance status, and systemic disease burden. The findings are intended to inform a shared decision-making approach with patients and their families.

Multidisciplinary Approach to Patients With Metastatic Spinal Cord Compression: A Diagnostic Therapeutic Algorithm to Improve the Neurological Outcome⁽⁴⁾

• Study Design: This is an original research article that proposes a diagnostic-therapeutic algorithm for managing patients with metastatic spinal cord compression. The algorithm is based on the experience of a primary care center and involves a multidisciplinary team.
• Target Population: Patients with vertebral metastases and symptoms of spinal cord compression.
• Key Factors: The study emphasizes the importance of early diagnosis and treatment to prevent neurological deficits. It outlines a step-by-step algorithm involving emergency room physicians, spine surgeons, neuroradiologists, radiation oncologists, and oncologists. The algorithm aims to optimize outcomes by ensuring timely MRI evaluation, surgical intervention, and systemic therapy

ANALYSIS OF EVIDENCE
Shared Findings^(2,4,5):

• All three studies emphasize the importance of a multidisciplinary approach in managing metastatic spinal tumors and spinal cord compression.
• They all highlight the need for early diagnosis and timely intervention to improve patient outcomes.
• The studies agree on the significance of effective pain management, local tumor control, and neurological decompression.

Differing Findings:

• Zaveri et al 2021⁽⁵⁾ focuses on the evolution of treatment strategies and the current standard of care involving limited decompression followed by postoperative SBRT.
• MacLean et al 2022⁽²⁾ provides a comprehensive summary of systemic considerations and their impact on clinical outcomes, emphasizing the need for a shared decision-making approach.
• Rispoli et al 2022⁽⁴⁾ proposes a specific diagnostic-therapeutic algorithm and highlights the role of a multidisciplinary team in optimizing patient outcomes.

Conclusion:
In summary, while all three studies underscore the importance of a multidisciplinary approach and early intervention, they each offer unique perspectives on the management of metastatic spinal tumors and spinal cord compression. Zaveri et al focus on treatment evolution, MacLean et al on systemic considerations, and Rispoli et al on a diagnostic-therapeutic algorithm.

References:

1. Schwake M, Maragno E, Gallus M, et al. Minimally Invasive Facetectomy and Fusion for Resection of Extensive Dumbbell Tumors in the Lumbar Spine. Medicina (B Aires). 2022;58(11). doi:10.3390/medicina58111613
2. MacLean MA, Touchette CJ, Georgiopoulos M, et al. Systemic considerations for the surgical treatment of spinal metastatic disease: a scoping literature review. Lancet Oncol. 2022;23(7):e321-e333. doi:10.1016/S1470-2045(22)00126-7
3. Al Farii H, Aoude A, Al Shammasi A, Reynolds J, Weber M. Surgical Management of the Metastatic Spine Disease: A Review of the Literature and Proposed Algorithm. Global Spine J. 2023;13(2):486-498. doi:10.1177/21925682221146741
4. Rispoli R, Reverberi C, Targato G, et al. Multidisciplinary Approach to Patients With Metastatic Spinal Cord Compression: A Diagnostic Therapeutic Algorithm to Improve the Neurological Outcome. Front Oncol. 2022;12:902928. doi:10.3389/fonc. 2022.902928
5. Zaveri GR, Jain R, Mehta N, Garg B. An Overview of Decision Making in the Management of Metastatic Spinal Tumors. Indian J Orthop. 2021;55(4):799-814. doi:10.1007/s 43465-021-00368-8

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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